The Electrocardiographically Circumflex Artery

A 39 yo otherwise healthy man with no risk factors was walking at the mall when he developed chest pressure.  He presented to the ED after 30 minutes, now also feeling weak.  He was diaphoretic.  Here was his initial ECG:There is sinus rhythm.  There is abnormal T-wave inversion in V2 which is abnormal and very suspicious There is minimal, nondiagnostic ST elevation in inferior leads with possibly a suggestion of reciprocal ST depression in aVL.  There are thin and normal inferior Q-waves. Thus, there are some suspicious abnormalities, but no definite signs of ischemia.   There is also minimal, nondiagnostic ST elevation in V5 and V6. Because of persistent symptoms, another ECG was recorded 30 minutes later:There is only one new finding on this ECG which suggests ischemia.  It is very subtle but real.  What is it?  See V3, where there is now some ST depression.  The previous ECG has a small amount of appropriate ST elevation in V3; any ST depression in a young male is abnormal, especially if changed from previous.  This is worrisome when combined with the abnormal T-wave in V2.Let's look at both V3's, magnified:The later ECG (bottom panel) shows minimal ST depression in V3.  The top shows minimal ST elevation (normal).  The difference is significant and highly suggests posterior ischemia.This abnormality in V3 was apparently not seen by the treating MD, who is a nationally recognized expert i...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs